Legal PTD Application Form

LEGAL PTD APPLICATION FORM

This Permanent Total Disability Application (the "Application") is made this by Applicant Name: ("Applicant") and Respondent Name: ("Respondent") for the determination and award of permanent total disability benefits under the governing statutory and contractual provisions described below.

RECITALS

WHEREAS, Applicant sustained an injury or occupational disease on or about arising out of and in the course of employment with Respondent, and such injury is the basis for a claim for permanent total disability (PTD);

WHEREAS, a claim has been asserted under claim number in the jurisdiction of ;

WHEREAS, Applicant submits this Application supported by medical evidence, vocational assessment, and other documentation to establish that Applicant is permanently and totally disabled as defined by applicable law and contract.

NOW, THEREFORE

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

For the purposes of this Application, the following terms are defined as follows:

"Permanent Total Disability" or "PTD" means a medical and vocational state of incapacity, arising from the compensable injury described above, that renders Applicant unable to engage in any substantially gainful employment and meets the criteria for PTD under applicable statutory or contractual standards.

2. APPLICATION AND DECLARATION

Applicant hereby applies for a determination of PTD based on the facts and evidence submitted. Applicant certifies under penalty of perjury that the statements made in this Application and in any attachments are true, complete, and correct to the best of Applicant's knowledge and belief.

3. MEDICAL EVIDENCE

Applicant shall attach and identify all relevant medical records, examinations, opinions, functional capacity evaluations, and other supporting evidence. Respondent may review, obtain independent examinations, and submit contrary evidence in accordance with applicable procedural rules.

4. AUTHORIZATION TO RELEASE RECORDS

Applicant authorizes any health care provider, facility, insurer, employer, or other entity in possession of relevant records to release such records to Respondent, Respondent's insurer, and to any appointed adjudicator or medical examiner. Applicant acknowledges that this release is limited to records reasonably related to the claimed injury and PTD determination.

5. REPRESENTATIONS, WARRANTIES, AND ATTESTATIONS

Applicant represents and warrants that Applicant has disclosed all prior claims, preexisting conditions, and material facts known to Applicant that bear on the present claim. Applicant further attests that Applicant has not intentionally misrepresented any material fact in connection with this Application.

Respondent represents that it will process the Application in accordance with the applicable standards, will allow reasonable discovery of relevant material, and will not unreasonably delay determinations required by law.

6. NOTICE INFORMATION

7. PROCESSING, HEARINGS, AND REMEDIES

The parties acknowledge that this Application may be processed administratively or adjudicated in a hearing forum. Any determination of PTD shall be made consistent with applicable evidentiary standards. The right to appeal or seek review of an adverse determination shall be preserved to the party entitled to such rights under the governing law.

8. GOVERNING LAW; VENUE

This Application and any adjudication or settlement arising from it shall be governed by and construed in accordance with the laws of the jurisdiction identified above. Venue for any proceeding initiated under or relating to this Application shall lie in the appropriate tribunal for that jurisdiction.

9. ENTIRE AGREEMENT; SEVERABILITY

This Application, together with attachments and any written agreements referring to this Application, constitutes the entire agreement of the parties with respect to the subject matter hereof. If any provision of this Application is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment to this Application will be effective unless in writing and signed by both parties. No waiver of any provision shall be deemed a waiver of any other provision. This Application may be executed in counterparts, each of which shall be deemed an original, and facsimile or electronic signatures shall be treated as originals for all purposes to the extent permitted by law.

11. ATTACHMENTS AND EXHIBITS

CERTIFICATION

The undersigned Applicant certifies under penalty of perjury that the information contained in this Application and the listed attachments is accurate and complete, and that Applicant has the authority to submit this Application on Applicant's own behalf. The undersigned Respondent certifies that the Respondent has received a copy of this Application and acknowledges receipt for processing purposes only.

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